Trends in malpractice claims for obstetric and gynecologic procedures, 2005 through 2014

BACKGROUND

Interest in medical malpractice and areas of medicolegal vulnerability for practicing obstetricians and gynecologists has grown substantially, and many providers report changing surgical practice out of fear of litigation. Furthermore, education on medical malpractice and risk management is lacking for obstetrics and gynecology trainees. Recent obstetric and gynecologic malpractice claims data are lacking. We report on recent trends in malpractice claims for obstetrics and gynecology procedures, and compare these trends to those of other medical specialties.

OBJECTIVE

We sought to evaluate recent trends in malpractice claims for obstetrics and gynecology procedures and compare these to other medical specialties.

STUDY DESIGN

A search was performed on all medicolegal claims data for obstetrics and gynecology procedures from Jan. 1, 2005, through Dec. 31, 2014, using the Physician Insurers' Association of America data-sharing project, which was created to identify medical professional liability trends. Data from 20 insurance carriers were reviewed based on a search using International Classification of Diseases, Ninth Revision codes and unique database-specific codes.

RESULTS

Of the 10,915 total claims closed from 2005 through 2014, the majority (59.5%) were dropped, withdrawn, or dismissed. The average indemnity of the remaining paid claims (31.1%) was $423,250. The most frequently litigated procedure was operative procedures on the uterus; 27.8% of cases were paid with an average indemnity of $279,384. The procedure associated with the highest proportion of paid claims was vacuum extraction. The average indemnity for paid obstetrics and gynecology procedural claims was 27% higher than that for all medical specialties combined. Obstetrics and gynecology procedural claims had the second highest average indemnity payment and the fifth highest paid-to-closed ratio of all medical specialties.

CONCLUSION

Litigation claims for obstetrics and gynecology procedures have higher average indemnity payments and higher paid-to-closed ratios than most other medical specialties. Claims most frequently relate to gynecologic surgery, but obstetric procedures are more expensive. Possible factors may include procedural experience and unique perioperative complications. We encourage efforts addressing procedures, litigation, and quality interventions to improve outcomes, mitigate risk, and potentially lower indemnity payments.

When Bleeding Is Vital: Surgically Ensuring the "Virginal" State

A young woman called me to ask for a referral to a physician who provided hymen reconstruction surgery. She had had premarital intercourse and came from a cultural background in which it was very important to "prove virginity" on the wedding night. This article deals with my internal struggle whether or not to provide the referral. I felt that providing it would have made me complicit in supporting gender inequality, as men are not required to "prove virginity" to get married. At the same time, I was concerned about the repercussions of not being able to "prove virginity" would have on the caller. I had no explicit guidance on what to do in such a situation--it was not covered by the professional responsibilities I had as a research assistant.

Establishing specialty jurisdictions in medicine: the case of American obstetrics and gynaecology

The profession of medicine has evolved into an extremely specialised occupation. Yet, recent research has neglected the intra-occupational processes influencing medical specialisation. This article aims to correct this oversight. It develops an historical account of intra-occupational factors influencing the decision to establish gynaecologic oncology as American ob/gyn's surgical subspecialty in 1972. Working within the framework initially developed by Everett C. Hughes and his students, the article examines this development as the outcome of a three-party relationship among gynaecologic oncologists, American ob/gyns, and gynaecologic pelvic surgeons. Aggressive movement by the gynaecologic pelvic surgeons challenging the established élite's identity definition for the ob/gyn specialty helped spur official recognition of gynaecologic oncology, a less threatening subspecialty. The article draws theoretical implications from the case regarding the role of a threatening other in influencing the specialisation process.

Intersex conditions in children and adolescents: surgical, ethical, and legal considerations

INTRODUCTION

Approximately one in 2000 children globally is born with an intersex condition. There is unfortunately a relative paucity of data on the choices and the surgical and psychosocial outcomes in patients who undergo genital surgery for intersex conditions and ambiguous genitalia, especially in developing countries. Specialists in these and other countries, where patient follow-up is generally poor, are faced with the daunting task of offering the appropriate medical and surgical management, in the absence of guidelines or recommendations.

SURGICAL CONSIDERATIONS

A surgical procedure in these patients sometimes involves clitoral recession, reduction, vaginoplasty, and gonadectomy. The best surgical outcome is likely to be achieved with a multidisciplinary surgical team; however, the choice of surgery and appropriate timing remains controversial. Some authors have suggested delaying surgery until the child becomes competent to make his/her own decisions.

LEGAL/ETHICAL CONSIDERATIONS

All procedures should conform to an ethical code of practice and be in the interest of the child. Exhaustive counseling of all parties and informed consent is of paramount importance, as is adherence to laws that protect the rights of the child as outlined in respective constitutions.

RECOMMENDATIONS

Recommendations in this article, which have been put together from the combined input of three departments, are broad-based. They emphasize the need for extensive counseling, informed consent, adherence to ethical and legal norms, a multidisciplinary input and a shift away from a paternalistic approach.

Obstetric and gynecologic malpractice in Turkey: incidence, impact, causes and prevention

The Forensic Medicine Association was established in Turkey by law number 2659 for the purpose of providing expertise in legal cases. In this study the opinions given by the lawcourts and public defenders in the Forensic Medicine Association's First, Second, Third, and Fifth Specialization Divisions between the years 1990 and 2000 (approximately 680,000 files) were examined retrospectively. It was determined from these that there were 636 cases of medical malpractice. In examining the distribution of cases based on specialty branch, it was established that 16.82% (n=107) were in the area of obstetrics and gynecology, 10.69% (n=68) in general surgery, 10.53% in neurology and neurosurgery, and the remaining areas were found to be at lower percentages. It also showed that in recent years there has been an increase in the number of cases claiming medical malpractice in the area of obstetrics and gynecology, and that 58% of the cases (n=62) from 1998 to 2000 were in this area. 96% of the 107 cases that claimed malpractice in the area of obstetrics and gynecology were found to be related to obstetrics and 3.8% (n=4) to gynecology and surgical procedures. In 31% (n=33) of the 107 cases fault was found; all of the cases where medical malpractice was found were in the area of obstetrics and none of the cases related to gynecology were found to have an element of error. Cases that had an element of error were evaluated from the aspect of profession of the health care personnel at fault, areas of fault, places where fault occurred, situations that resulted in death, cause of death, whether or not an autopsy was done, injury that resulted from fault, intervention that was done, and obstetric and gynecologic risk factors that set the stage for claims. Care standards and breach of standards were examined.

ACOG Committee Opinion, Number 289, November 2003. Surgery and Patient Choice: The Ethics of Decision Making

The purpose of this Committee Opinion is to provide the obstetrician-gynecologist with an approach to decision making based on ethics in an environment of increased patient information, recognition of patient autonomy, direct-to-consumer marketing, and many alternative or investigational treatments. A process for ethical decision making in surgery is discussed, illustrated by an example of elective cesarean delivery.

Laparoscopic bowel injuries: forty litigated gynaecological cases in Canada

OBJECTIVE

To review the clinical circumstances and the clinical and legal outcomes of 40 laparoscopic bowel injuries that were litigated in Canada.

DESIGN

Retrospective review of 40 litigated cases of laparoscopic bowel injury, from 1990 to the end of 1998, provided by the Canadian Medical Protective Association (CMPA).

MEASUREMENTS AND MAIN RESULTS

The laparoscopy was performed for diagnosis (n = 13), tubal occlusion (n = 15), and as an operative therapeutic procedure (n = 12). Injuries were related to the initial peritoneal entry in 22 (55%) women (19 during the closed technique and 3 with the open technique). Of these, the injury was due to the primary trocar (n = 17), scalpel (n = 1), Veress needle (n = 1), Veress needle or undetermined (n = 2), and fascial suture (n = 1). The small bowel was injured in 9 of 11 entries by the trocar during diagnostic laparoscopy and in 6 of 14 tubal occlusions. Five injuries in the tubal occlusion group were attributed to "cautery." The injury was recognized intra-operatively in 55% of cases. The clinical outcome was uncomplicated in 85% of patients. There was no difference in clinical outcome between small versus large bowel injuries and between intra-operative versus post-operative diagnosis of the injury. The litigation outcome was favourable to the physician in 75% of cases. Recognition was delayed in 45% of cases and this was associated with 67% of the litigation outcomes unfavourable to physicians.

CONCLUSIONS

(1) The initial laparoscopic entry into the peritoneal cavity remains the major contributor to bowel injury in laparoscopic surgery. (2) The open (Hasson) technique does not prevent bowel injuries. (3) Delayed recognition was a major factor in assessment of liability.